MANAGING HEPATITIS -- Insurance Information


If you are dealing with hepatitis, it is particularly important that you understand how the insurance world works. Once diagnosed with hepatitis B or C, insurance carriers are likely to regard you as a "high-risk" individual.

But health insurance coverage is regulated by federal and state laws. They extend varying degrees of protection to people with chronic illnesses like hepatitis. You will want to find out what regulations and safeguards your state's insurance laws provide for you.

Health insurance

If you or a spouse are covered by a group medical policy when you are diagnosed with hepatitis, your family will not be excluded. But the extent of coverage may depend to a great extent on whether coverage is through a fee-for-service plan, a preferred provider organization (PPO), or a health maintenance organization (HMO). While the latter two (often referred to as managed-care plans) are generally more economical, their goal is to keep costs down -- which frequently raises more issues for a person with chronic hepatitis.

Fee for Service:

This is the most expensive form of health insurance, and but usually offers a patient full freedom of choice in terms of which doctors to see for medical care. These plans typically have an annual deductible amount you must spend on health care before the insurance company pays. Beyond that amount, the insurance company generally pays 80 percent of what they view as a reasonable charge for a service -- even if your doctor charges a higher amount -- leaving you to pay the difference.

Preferred Provider Organization (PPO):

The preferred provider organization gives patients the choice of seeing a doctor who is part of that PPO's network, or seeking care with a non-participating physician. While 90 percent of the cost normally is covered if you go inside the network, typically only 70 percent is covered if you see a doctor outside the network.

Health Maintenance Organization:

In a Health Maintenance Organization, the patient's care generally is coordinated by a primary care physician, who acts as a gatekeeper and controls your access to specialists, tests and procedures. Some HMOs may not even have hepatologists or gastroenterologists familiar with hepatitis as part of the HMO network. Others may require that you get approval from the gatekeeper before you can go to an emergency room.

With any of these plans, it is important to find out what access you will have to treatments, medications, and tests. Most plans now have "formularies" -- lists of drugs for which they will pay. It is crucial to find out what medications are covered. And even if the medication is covered, will your plan pay for it if it has not yet been officially approved by the FDA for your condition

Another question of particular interest to a patient with chronic hepatitis is whether your plan has a lifetime coverage cap -- or maximum dollar amount -- for each insured person. Many plans have a lifetime cap of $1 million, which can be exhausted in not too many years by a person with a chronic condition like hepatitis. Some plans also set annual caps, and caps on the amount they will pay annually or over the lifetime toward for medications.

The Good News:

While you may have to cope with a variety of restrictions, group insurance plans cannot deny you coverage because you have hepatitis.

Under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), if you had prior health insurance coverage for 12 consecutive months, with no lapse in coverage of more than two months, the insurer cannot refuse coverage on any pre-existing conditions.

And even if you did not have prior coverage, the group policy can only refuse to pay for pre-existing medical problems such as hepatitis for a maximum of 12 months (up to 18 months for late enrollees in group health plans).

The Not-So-Good News:

HIPPA does not apply to individual health insurance policies, so treatment for hepatitis may be excluded. It is always best to ask questions and research new policies very carefully. State laws may also help restrict limitation of pre-existing conditions in individual health insurance policies.

Whether you are enrolling in a group or an individual health insurance plan, the insurer usually asks general health questions. It is important to answer honestly with all relevant information. Insurance companies frequently use an organization called the Medical Information Bureau (MIB) to obtain information about an individual or a family's medical claims history.

Life insurance

Insurance companies can refuse to underwrite life insurance for those infected with hepatitis. For most policies, a routine blood test is required. Liver enzymes in the blood are tested and if they are high (indicating hepatitis), most applications for life insurance will be denied.

Adverse medical and blood test information is usually reported to the Medical Information Bureau and shared with other participating insurance companies. An insurance report of "liver enzymes, abnormal" may also prevent you from receiving coverage from other companies.

Some insurance companies may underwrite hepatitis and will offer a policy for those at risk with surcharges of 200-to-400 percent of a standard rate. As a service to Hepatitis Week subscribers, we will list some of the companies providing life insurance for hepatitis patients in the months ahead.

Other options include group life insurance through an employer, an association or organization. Group insurance generally provides relatively low amounts of coverage, and blood tests generally are not required. When you leave the group, you may also lose your insurance.

If You Can't Obtain Insurance

Disability Benefits in the United States

If you suffer from hepatitis, and cannot obtain health insurance coverage, you may be eligible to receive disability benefits from the Social Security Administration.

According the to Social Security Administration the definition of "disability" is as follows:
"Disability under Social Security is based on your inability to work. You will be considered disabled if you are unable to do any kind of work for which you are suited and your disability is expected to last for at least a year or to result in death."

To get information from the Social Security Administration, call 1-800-772-1213.

If You Can't Afford Interferon Treatment

Schering-Plough, the manufacturers of Intron-A interferon, have a cost sharing program called "Commitment to Care" designed to help those in need of interferon therapy who are unable to afford it. The program is based on a sliding-scale based on income, with the cost ranging from free in some cases to whatever their scale says you can afford. They will first try to find programs in your State that may help, and if none is found, they will determine what you are able to pay and absorb the rest of the cost.

In the US: The number to call for the "Commitment to Care" program is 1-800-521-7157, extension 147.
In Canada: The number to call is 1-800-603-2754 extension 2121.

All information provided in this site is offered for educational purposes only, and it is not intended nor implied to be a substitute for professional medical advice. Always consult your own physician or healthcare provider with any questions you may have regarding a medical condition.